REPUBLIC OF THE PHILIPPINES) City of Santiago) S.S. AFFIDAVIT OF UNDERTAKING (Sickness Benefit Clam) of legal age, Filipina citizen, married, with Santiago City after having bean duly sworn that 1 MAGDALENA M _DELA CRUZ. address at # 005 carreon St, Centro East in accordance with law, hereby depose and st That | am currently an active voluntary member of the Social Gecurity System (SSS) with SS Number 0120158007, 1 That | was diagnosed as a positive confirmed case of COVID 19 last 2022 by Dr Eunice Stefanelle A Sibuyan and was advised to hile taking medications prescribed January 13. undergo home isolation for 10 days wi 3. That my income was sencusly affected during the time | have undergone the required isolation penod making myself financially challenged at the present That | am executing this affidavit for the purpose of claiming sickness benefits as a bonafde member of the Social Security System (SSS) which may aid me to recuperate from my current financial situation, | have also ‘e supporting documents necessary to substantiate & hereunto attach al my claim, 5 That | am aware that | may be criminally liable for any false statement or representation made in this document or for any other documents submitted in connection with my claim, and 6 That | am executing this affidavit to attest truthfulness, veracity and due ‘execution of the foregoing statements and documents. IN WITNESS WHEREOF. | have hereunto set my hands this 23rd day of February 2022 at Santiago City, Philippines. MAGOALENA MDELA CRUZ Affiant CTC # 07116527 SUBSCRIBED AND SWORN to before me this 12th day of February, 2022 at Santiago City, Philppines, affiant exhibiting her Community Tax Certificate issued on January 27, 2022 at Santiago City, Isabela \ (i ATTY ABRAT Doe No Ub aRALTM Bh SAD Page No c% pret Se Book Nos Senies Nong E15, vam obueaaga 5